Operational Guide: GLP-1 Eligibility, Workflows & Escalations

This guide outlines the operational workflows, clinical eligibility criteria, and escalation paths for Vida’s Medical Weight Loss (MWL) program and GLP-1 Prescribing services.

As an Agent, you will use this document to determine if a member qualifies for medication, understand the required clinical steps (such as lab validation), and handle complex scenarios like "Behavior Pathway" transitions or exception requests. Always cross-reference this guide with the specific Pay Org Knowledge Base article or VP Card, as client rules vary significantly.

Program Overview

As of January 1, 2024, Vida expanded its Medical Weight Loss (MWL) program to offer Anti-Obesity Medications (AOMs)—specifically GLP-1s—to eligible members. GLP-1s are effective for both weight loss and diabetes management.

Eligibility Factors

Coverage and eligibility are complex and depend on a combination of:

• Pay Org: (Check the specific VP Card/KB Article).

• Program: (MWL, Whole Health, or Weight Loss).

• Conditions: (Obesity or Diabetes).

• Ethnicity: (affects BMI cutoff).

• Current Meds: (Whether the member is already prescribed a GLP-1)

 Clinical Eligibility: BMI & Ethnicity

A screener in the onboarding experience captures the member’s ethnicity. This is critical because the BMI threshold for the MWL program differs by demographic to account for physiological differences.

Note: Use the BMI Calculator to confirm a member's status if they are inquiring about eligibility.

Onboarding & Enrollment Logic

The system automatically recommends programs based on the screener data.

• If Eligible: The Medical Weight Loss (MWL) program will appear as a recommended option.

• If Ineligible: MWL will not appear in the list of program options.

  • Agent Action: If a member demands MWL but it is not listed, they do not meet the clinical criteria. Refer to the Pay Org specific article to redirect them accordingly.

The Prescribing Workflow (Care Team)

Once enrolled in MWL, the member follows a strict provider sequence to ensure safety before medication is issued.

1. Registered Dietitian (RD):

   • Action: Completes Medical Intake Part 1.

   • Goal: Establish nutrition care and dietary baseline.

2. Vida Medical Provider (VMP):

   • Action: Completes Medical Intake Part 2.

   • Goal: Reviews labs, medical history, and makes the final decision on GLP-1 prescribing.

   • Note: Agents should refer to these providers as "Vida Medical Providers" (VMP), not "prescribers."

3. Health Coach:

   • Action: Added last to the team.

   • Goal: Long-term behavior change and accountability.

Lab Requirements & Validation

Members are blocked from scheduling their VMP consult until specific labs and medical recordss are ingested and validated.

Required Labs:

• A1C

• TSH (Thyroid Stimulating Hormone)

• Lipid Panel

• CMP (Comprehensive Metabolic Panel)

When a member submits a lab document, it must meet ALL of the following:

• [ ] Identity: Member Name and DOB must match the Vida account.

• [ ] Recency: Collection date must be within the last 12 months.

• [ ] Format: Must appear to be an original medical document (no handwritten required fields).

• [ ] Data: Must contain all of the required test groups (CMP, Lipid, TSH, or A1C).

Required Medical Records Must Include:

• Name
• Date of birth
• Date of test or prescription
• Test or prescription name
• Test result, value, or dosage
• Name of the prescriber
• BMI at the time

The Behavior Pathway (Off-Ramping)

Not all MWL members will receive or stay on medication. Members may be moved to the Behavior Pathway (no meds) if:

• They do not meet clinical criteria for a prescription.

• They have been on meds for 12 weeks and have not lost 5% of their body weight.

What this means for the member:

• They are temporarily discharged from prescribing.

• They remain in the MWL program with their RD and Coach.

• Reassessment: They can be re-evaluated for medication after 12 weeks if they demonstrate engagement (e.g., 4+ RD sessions).

Scripting (Macro: Behavior Pathway):

Our program is designed to promote long-term success and sustainable weight loss through a comprehensive, evidence-based approach. As part of your care, you will continue to have access to a registered dietitian (RD). We will also monitor your laboratory results and blood pressure regularly to assess improvements in your risk factors and overall health. Adjustments to your care plan will be made as needed to support your continued progress.

 

Please note that this decision is final and consistent with our clinical policy. You are not being removed from the Medical Weight Loss program. You will continue working with your RD and coach and will maintain full access to the Vida platform. However, you are being referred to the behavioral change component of the program and are being temporarily discharged from the medication-prescribing pathway.

 

If, after 12 weeks of consistent engagement with your RD and coach, your weight-loss goals have not been met, we will reevaluate your plan. This process ensures that we are delivering the highest standard of care in alignment with peer-reviewed research and evidence-based guidelines 

Escalations & Exceptions

A. Exception: "Previously on GLP-1"

If a member does not meet the current BMI cutoff (e.g., they lost weight on a previous drug) but wants to continue therapy:

• Requirement: They must prove they met the criteria at the time of their initial prescription.

• Evidence Needed:

  1. Evidence of previous GLP-1 prescription (screenshot/pharmacy record).

  2. Evidence that starting BMI was eligible (33+ or Pay Org specific).

  3. Supporting letter from their physician.

• Action: Advise the member to submit the evidence into the docuents section of the app and follow the Clinical Review/ Override KB article instructions

B. Exception: MWL Enrollment Denials

If a member was not offered MWL during onboarding but insists they are eligible:

1. Check: OOE Logic

   • If the member seems to fall within all the guidelines and no exclusions are found submit a JIRA to have the member added to the program

   • If the exclusion is found then the member is clinically ineligible. Follow ineligible member instructions in the org specific KB article

2. Review: If they demand a Clinical Review:

   • Trigger the Clinical Review/Exception Process 

C. Attestation Forms (Ascension Only)

• Scenario: Member is enrolled but Pharmacy rejects the claim.

• Action: If an enrolled member is currently having their prescription rejected by the pharmacy, we have a process in place to send the member an attestation form in the app to be shared with their prescriber. This provides the prescriber with attestation of the member’s enrollment in Vida so the prescriber can update this in the prior authorization form. Unfortunately, there is currently no automated process for Vida enrollment to be processed by the PBM, so this is a short term solution to help member’s get PA for these meds.

• If Ascension members are getting a rejection at the pharmacy and need a Prior-Auth Attestation letter, please add the macro " Ascension Prior Authorization (PA) Attestation Letter Request," add the member's UUID, and post to the #urgent-prior-auth-mitigation channel via a Slack Side-Conversation. These should be actioned and filled within 48 hours by the prodops team. Remember that this is only for Ascension SmartHealth members and we do not currently send attestation letters for any other orgs.
• Send the member the Ascension PA Attestation Document and Comms Sent macro response after the letter is requested.